Provider Demographics
NPI:1962543504
Name:KHUMOORO, SAM PUTRES (DC)
Entity type:Individual
Prefix:DR
First Name:SAM
Middle Name:PUTRES
Last Name:KHUMOORO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23080 ALESSANDRO BLVD STE 204
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-9674
Mailing Address - Country:US
Mailing Address - Phone:951-571-4090
Mailing Address - Fax:951-571-4091
Practice Address - Street 1:23080 ALESSANDRO BLVD STE 204
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9674
Practice Address - Country:US
Practice Address - Phone:951-571-4090
Practice Address - Fax:951-571-4091
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC-25727111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor